Recommendations for Tuberculosis (TB) Screening in Long Term Care and Retirement Homes

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2 Recommendations for Tuberculosis (TB) Screening in Long Term Care and Retirement Homes healthful Recommendation for Residents All new residents must undergo a history and physical examination by a physician/nurse practitioner within 90 days prior to admission or within 14 days after admission. It is recommended that this assessment include: 1. A symptom review for active pulmonary TB disease. 2. A chest x-ray (posterior-anterior and lateral) taken within 90 days prior to admission to the facility. 3. If signs and symptoms and/or chest x-ray indicate potential pulmonary TB disease, the resident should not be admitted until three sputum samples taken at least eight hours apart are submitted to the Public Health Lab for testing (Acid Fast Bacilli and Culture) and the results are negative. Note: It can take up to 8 weeks for a culture report. 4. In addition to the above, for residents < 65 years of age who are previously skin test negative or unknown, a 2-step tuberculin skin test (TST) is recommended. If the TST is positive, treatment of latent TB infection (LTBI) should be considered. A TST is not recommended for residents with a previous positive TST. Tuberculin skin tests are not recommended to be done upon admission for residents 65 years of age or older. If a TST was previously done, record the date and result of the most recent TST. Recommendations for Residents admitted to Short Term Care of less than 3 months (e.g. Respite care) Residents in facilities for short term care should receive an assessment and symptom review by a physician/nurse practitioner to rule out active pulmonary TB, within 90 days prior to admission or within 14 days after admission. If the symptom review indicates potential active pulmonary TB disease, a chest x-ray must be obtained and active TB disease ruled out (see #3 above). A TST for residents in short term care is not recommended. Management of Residents with Suspected Active TB Disease If at any time, active pulmonary TB disease is suspected in a resident, the individual should be isolated immediately. This involves placing the resident in a single room, keeping the door closed, limiting interactions with staff and visitors and ensuring appropriate personal respiratory protection (i.e. have resident wear a surgical mask, if tolerated while others are in the room; N95 masks are recommended for staff and visitors). Immediate steps should be taken to ensure appropriate medical care, investigation and follow-up according to facility policies and procedures. The local Public Health Unit should be notified and consulted regarding next steps. Reporting Requirements for Tuberculosis Under the Health Promotion and Protection Act, R.S.O. 1990, c. H.7, diagnoses of TB infection and cases of suspect and confirmed active TB disease are reportable to Public Health. For information on how to report or to ask for advice related to TB infection or TB disease, please contact your local Public Health Unit. Bureau de santé Porcupine Health Unit Questions?

3 Recommendations for Employees and Volunteers The following assessment must be initiated within 6 months before starting work or within 14 days of starting work: Person with unknown TST Person with documented results of previous 2-step TST *Person with a positive TST A 2-Step TST is required If both tests were negative If any previous test was positive Report person with positive TST to local Public Health Unit If both tests are negative If either test is positive Done > 6 months ago Done < 6 months ago Refer to *Person with a positive TST A physical exam including symptom review and a chest x-ray are recommended to rule out active TB disease. Note: The chest x-ray can be from within the last three months unless the person is symptomatic. Further skin testing is not recommended. The person should be informed of the signs and symptoms of active TB disease. No further testing is recommended Refer to *Person with a positive TST A 1-step TST is necessary Note: If the result of this TST is positive, refer to *Person with a positive TST No further testing is recommended If person has symptoms of TB or an abnormal chest x-ray: Collect 3 sputum samples at least 8 hours apart Should not work until physician provides documentation that the person does not have infectious TB disease. If person has no symptoms: Can continue to work while physician completes assessment to rule out infectious TB disease Note: Persons with medical conditions that severely weaken the immune system may have a negative TST even though they have TB infection. Recommend further assessment by a specialist with expertise in tuberculosis (e.g. Infectious Disease, Respirologist, TB Clinic). Volunteers include those who expect to work regularly during the next year (approximately a half day per week or more). Requirements for Contract Workers and Students Supplying agencies or schools are responsible for pre-placement TB assessment and follow-up. This should be clarified with agencies or schools to confirm that individual contract workers and/or students have had their TB skin test and any additional assessment as needed to rule out TB disease prior to starting the placement. Regular Screening for Residents, Employees and Volunteers Annual TB skin testing is not recommended. Annual chest x-rays are also not recommended in the assessment of positive reactors. If an infectious case of active TB disease occurs in the facility, contact follow-up will be coordinated by the local Public Health Unit. TB skin testing is free for persons identified as a contact of a case of TB disease. Medication for treatment of TB infection and TB disease is free through Public Health. Adapted from Toronto Public Health March 2014

4 Tuberculosis (TB) Screening in Long Term Care and Retirement Homes Frequently Asked Questions healthful 1. Why are TB skin tests (TSTs) no longer recommended for residents age 65 years and over? The Canadian TB standards, 6 th edition (CTS 2007) advises that residents of Long Term Care Institutions undergo baseline posterior-anterior and lateral chest x-rays. If the resident has documented results of a prior TST, these should be transcribed into their record. However, if no prior TST results are available, the decision to perform a routine baseline TST is controversial as the primary purpose of TSTs on admission to long term care is to establish a reliable baseline TST for comparison to repeat TSTs in the event that the resident is exposed to an infectious TB case in the facility. Routine TSTs upon admission are no longer recommended for clients 65 years of age and older. As people reach old age, the TST may become increasingly unreliable and difficult to interpret. In this population, the TST may not become positive even after a significant TB exposure. As well, unless there is a documented 2-step TST on record, testing after exposure may result in the boosting effect being misinterpreted as a true conversion. Most critically, even for elderly individuals who do convert to a positive TST following a TB exposure, prophylaxis is often not possible, due to their decreased ability to tolerate the hepatotoxicity of Isoniazid (INH). For an elderly person exposed to infectious TB, the most important follow-up is ruling out active TB via careful evaluation of symptoms, CXR, and where indicated, 3 sputum samples taken at least 8 hours apart. Clients under 65 years of age who have a positive TST are more likely to be candidates for TB prophylaxis. In addition to the symptoms review for active pulmonary TB disease and chest x-rays, a 2-step TST is required for those less than 65 years of age, unless a previous TST is known to be positive. 2. What is a 2-step skin test for TB? This consists of 2 TST s usually performed within 1 to 4 weeks of each other. A 2-step TST, rather than a single TST, is generally only indicated at the initial assessment of someone who will be having repeat TSTs at regular intervals. For example, a 2-step TST is recommended for health care workers at the start of employment, to help reduce the chance of a newly-positive TST in the future being misinterpreted as conversion when the TST is repeated. The 2-step TST needs to be performed only once if properly done and documented (Canadian Turberculosis Standards 6 th Ed.CTS 2007). Over decades, the immune response (i.e. a positive TST) related to a remote TB or BCG exposure can go dormant. A single TST may elicit a negative result; however, re-stimulates the immune recognition so that a 2nd TST at a later time will elicit a much greater response. The reason for a 2-step TST is to detect this booster effect at the beginning of TST monitoring (using a 2-step TST), as otherwise it could be confused later on with a true TST conversion. Questions? Bureau de santé Porcupine Health Unit

5 3. What is recommended for residents being transferred from another facility? Prior to transfer, the resident should be carefully reassessed for signs and symptoms of active TB, including failure to thrive. This should also include a review of the chest x-ray previously done upon admission to the facility or any more recent radiology. You may wish to use the active TB screening checklist for clinicians to guide the symptom and chest x-ray review. If there are any indications of possible active TB, a repeat chest x-ray, sputum testing, and any other necessary investigations should be done to rule out active pulmonary TB disease before the resident is transferred. 4. What if a new employee/volunteer had a 2-step TST done, but the 1 st and 2 nd steps were done more than 4 weeks apart? According to the Canadian TB Standards, the 1 st and 2 nd step of a 2-step TST should be done 1-4 weeks apart. Less than 1 week does not allow enough time to elicit the phenomenon, more than 4 weeks allows the possibility of a true TST conversion to occur if the person had an exposure to infectious TB in the interim. However, the 2 nd step can be accepted up to 1 year later as long as no exposure to active TB occured within the time in between. 5. What if an employee/volunteer has never had a 2-step TST done, but had a 1-step TST done within this past year? If the previous TST result was positive ( 10 mm), no further skin testing should be done. The person should proceed with a physical exam and a chest x-ray to rule out active TB disease. If the previous TST was negative, another 1-step can now be done and accepted as the 2 nd step of a 2-step TST as long as it is within a 1-year period from the time of the 1 st step. It is important to assess the likelihood that the employee was exposed to active TB since the last TST. If an exposure is suspected, the 2 nd TST should be done at least 8 weeks after the TB exposure in order to provide a reliable baseline for future assessments. 6. A resident had a CXR done 2 months ago but now has symptoms that could be due to active pulmonary TB. Should a repeat CXR be done prior to admission to our facility? Yes. If the resident has symptoms suggestive of active TB (i.e. cough lasting longer than three weeks, unexplained weight loss, fever, chills, night sweats, fatigue), a current chest x-ray should be done to rule out active pulmonary TB disease. In addition, 3 sputum samples should be collected at least eight hours apart and submitted to the Public Health Laboratory for testing (Acid Fast Bacilli and Culture). Before admitting the resident, all sputum results should be negative and active pulmonary TB disease ruled out. If the resident has already been admitted to the facility, refer to the Recommendations of TB Screening in Long Term Care and Retirement Homes, specifically the section regarding Management of Residents with Suspected Active TB Disease. 7. If a staff person has received the BCG vaccine in the past do they still need a TST? Yes. TB skin testing is required for staff who have received BCG vaccines in the past. People vaccinated with BCG may have a positive TB skin test if the BCG was given after infancy. However it is also possible for this positive TST to have been caused by TB infection, especially if the person was born in or travelled to a country with high rates of TB. It is worth remembering that countries with much higher rates of TB than Canada also use BCG routinely. Thus, adults with a positive skin test who had a BCG vaccination should still be carefully evaluated for possible latent TB infection (LTBI), and be offered treatment for LTBI if appropriate. The following resources may be helpful in interpreting a positive TST: On-Line TST/IGRA interpreter may be found at BCG World Atlas - A Database of Global BCG Practices and Policies may be found at International TB rates by country at Adapted from Toronto Public Health March 2014

6 Tuberculosis (TB) Screening in Long Term Care And Retirement Homes Active TB Screening Checklist for Clinicians Please remember, the elderly may not present with classic signs and symptoms of active TB Disease. In the elderly, consider tuberculosis in the differential diagnosis of failure to thrive and unexplained fatigue. Cough greater than 3 weeks Hemoptysis Fever Night sweats Unintentional weight loss Anorexia Chest pain Dyspnea Cavities Infiltrates Nodules Pleural effusions Symptom Yes No Comments Chest x-ray findings Yes No Comments Hilar or mediastinal lymphadenopathy Changes in apices of lungs Densities Volume loss Fibrosis Granulomas Reference: Ministry of Health and Long-Term Care. Tuberculosis Protocol (Version 1.0). Diagnostics. P. 55; Public Health Agency of Canada & The Lung Association (2007). Canadian Tuberculosis Standards (6 th Ed.). Chapter 4 Diagnosis of Tuberculosis Infection and Disease. P.73 If there are concerning findings on either the review of symptoms or the chest x-ray, three sputums for acid-fast bacilli (AFB) and culture should be ordered for collection at least 8 hours apart, to rule out active TB. Please contact the ID intake nurse for assistance in managing a case or March 2014 Adapted from Toronto Public Health